Editor's Choice: Contemporary Treatment of Popliteal Artery Aneurysm in Eight Countries: A Report from the Vascunet Collaboration of Registries

Sex disparities in popliteal artery aneurysms

OBJECTIVE

Only 5% of patients with popliteal artery aneurysms (PAAs) are female. Evidence on PAA treatment and outcomes in women is therefore scarce. The POPART Registry provides one of Europe's largest data collections regarding PAA treatment. Data on clinical presentation, aneurysm morphology, and perioperative outcomes after open surgical PAA repair in women will be presented.

METHODS

POPART is a multicenter, noninterventional registry for open and endovascular PAA repair, with 42 participating centers in Germany and Luxembourg. All patients aged >18 years who have been treated for PAA since 2010 are eligible for study inclusion. Data collection is based on an online electronic case report form.

RESULTS

Of the 1236 PAAs, 58 (4.8%) were in women. There were no significant differences in age or cardiopulmonary comorbidities. However, female patients had a lower prevalence of contralateral PAAs and abdominal aortic aneurysms (P < .05). PAAs in women were more likely to be symptomatic before surgery (65.5% vs 49.4%; P = .017), with 19% of women presenting with acute limb ischemia (vs 11%; P = .067). Women had smaller aneurysm diameters than men (22.5 mm vs 27 mm; P = .004) and became symptomatic at smaller diameters (20 mm vs 26 mm; P = .002). Only 8.6% of women and 11.6% of men underwent endovascular aneurysm repair (P > .05); therefore, the perioperative outcome analysis focused on open surgical repair. In total, 23.5% of women and 16.9% of men developed perioperative complications (P > .05). There were no differences in major cardiovascular events (P > .05), but women showed a higher incidence of impaired wound healing (15.7% vs 7.2%; P = .05) and major amputation (5.9% vs 1.1%; P = .027). Female sex was significantly associated with the need for nonvascular reinterventions within 30 days after surgery (odds ratio: 2.48, 95% confidence interval: 1.26-4.88), whereas no significant differences in the odds for vascular reinterventions were observed (odds ratio: 1.98, 95% confidence interval: 0.68-5.77). In the multiple logistic regression model, female sex, symptomatic PAAs, poor quality of outflow vessels, and graft material other than vein graft were independently associated with perioperative reinterventions.

CONCLUSIONS

Women have smaller PAAs, are more likely to be symptomatic before treatment, and are more often affected by nonvascular reinterventions in the perioperative course. As our understanding of aneurysmatic diseases in women continues to expand, sex-specific treatment strategies and screening options for women in well-selected cohorts with modified screening protocols should be continuously re-evaluated.

Emergency treatment of popliteal aneurysms: Single center experience and systematic review and meta-analysis of endovascular versus open repair

BACKGROUND

Popliteal artery aneurysms (PAA) were traditionally treated by open repair (OR). Endovascular repair (ER) has become a new treatment strategy. The aim of this systemic review and meta-analysis was to evaluate and compare the current outcomes of OR and ER in the emergency treatment of PAA.

METHODS

A systematic literature search of the PubMed/Medline database was carried out. Outcomes were 30-day mortality, morbidity, major amputation rate (30 days), major amputation rate (1 year), 1-year primary patency rate, 1-year secondary patency rate and 1-year survival. Additionally, we included clinical data of patients with popliteal aneurysms treated between 2009 and 2021 at the Martin-Luther University Halle-Wittenberg.

RESULTS

We identified two cohort studies from 2014 and 2015 with a total of 199 patients that underwent emergent surgery (39 ER and 160 OR). We also included 26 patients from our institution. For emergency treatment, 30-day major amputation rates (18% vs 3%, Odds Ratio 5.82, 95% CI [1.75; 19.30], p = .004), 30-day mortality rates (10% vs 1%, Odds Ratio 5.57, 95% CI [1.01; 30.58], p = .05), 1-year major amputation rates (15% vs 6% Odds Ratio 3.61, 95% CI [1.18; 11.09], p = .02), 1-year loss of primary patency (54% vs 23%, Odds Ratio 3.19, 95% CI [0.91; 11.20], p = .07), and 1-year loss of secondary patency (44% vs 12%, Odds Ratio 6.91, 95% CI [3.01; 15.83], p < .05) were higher in the ER group when compared to the OR group.

CONCLUSION

Endovascular repair represents an alternative approach for the emergency treatment of PAA. Limited evidence from the available non-randomized studies shows unfavorable outcomes for patients undergoing ER. However, the results are prone to selection bias, and only randomized trials comparing ER to OR might reveal whether a subgroup of patients would benefit from ER as primary treatment of PAA in an emergency setting.

Repeated Pseudoaneurysm after Endovascular Repair of Popliteal Aneurysm due to Graft Disintegration and Fabric Tear

Endovascular repair of popliteal artery aneurysms (PAA) using a stent graft is suitable for patients with favorable anatomy. In the domestic situation where Gore Medical withdrew, we report two cases of unusual complications of pseudoaneurysm after endovascular repair of PAA. A 44-year-old male with a history of bypass surgery for a PAA presented with recurrent vein graft pseudoaneurysm. Endovascular treatment using a domestic stent graft was performed. However, pseudoaneurysm developed due to the graft fabric tear 1 month later, requiring surgical removal. In another case, an 84-year-old female presented with acute limb ischemia related to PAA. Endovascular aneurysm repair with the same domestic stent graft was performed. However, stent graft failure occurred 2 years later and the patient underwent open surgical repair. There was a graft fabric disintegration. When proper endovascular device is not available, open surgical treatment is the best option for treating PAA.

Nationwide cross-sectional epidemiological analysis of 3,306 lower limb peripheral aneurysm repairs in Brazilian public hospitals between 2008 and 2019: trends, mortality and costs

BACKGROUND

Although peripheral aneurysms can be limb or life threatening, the literature is scarce and there are only two large population-based epidemiological studies on peripheral aneurysm repair, comprising data from high-income countries only.

OBJECTIVE

To evaluate the epidemiology of peripheral aneurysm repairs in the Brazilian Public Health System, which exclusively insures more than 160 million Brazilians.

METHODS

retrospective cross-sectional analysis on open and endovascular peripheral aneurysm repairs performed in public hospitals between 2008 and 2019 using a public database.

RESULTS

3,306 peripheral aneurysm repairs were observed. Most patients were elderly (57.74%) male (72.66%) and patients treated with endovascular repair were older (p=0.008). Most repairs were emergency (59.56%) and open (93.8%) and there was an overall downward trend in procedure rates. We observed a decreasing predominance of emergency open repair over elective open repair (p<0.001), but open repairs prevailed over endovascular procedures, with no tendency to change this predominance. Mortality rates were 3.12% and 3.67% after elective and emergency open repair, respectively, with no difference, and 0 and 4.24% for elective and emergency endovascular repair, respectively. The government reimbursed an average of $1170.05 for open PA repair and $1802.01 for endovascular repair.

CONCLUSIONS

We presented the largest series of the literature analyzing all 3,306 lower limb peripheral aneurysm repairs performed in public hospitals in a middle-income country. Procedure rates tended to decrease. Open repair predominated. Mortality rates ranged from 0 to 4%. Most procedures were emergency, but there was a relative increase of elective treatments over the years.

Real-world data of popliteal artery aneurysm treatment. Analysis of the POPART registry

OBJECTIVE

Popliteal artery aneurysm (PAA) is a rare disease with a prevalence of 0.1-1%. Within the last years, endovascular repair of PAA (ER) has been performed more frequently despite the lack of high-level evidence compared to open surgery (OR). In 2014, the POPART registry was initiated to validate current treatment options in PAA repair.
 METHOD: POPART is a multinational multicenter registry for peri- and postoperative outcome of endovascular and open PAA repair. Data sets are recorded by the online survey tool "SurveyMonkey®". Regular monitoring and plausibility checks of the data sets are performed to ensure reliability. The aim of this study is to present results of the POPART registry, with data of 41 centers.
 RESULTS: From June 2014 to August 2019, a total of 794 cases were recorded in the PAA registry. OR was performed in 662 patients and ER in 106 patients; 23 Patients were treated conservatively. Four of the 106 patients with primary ER underwent conversion to OR. ER patients were significantly older (ER x˜= 71 vs. OR x˜= 67 (p<0.05). There were no other significant differences in demographics or comorbidities and aneurysm morphology between the two groups. 50.3% patients in the OR group were symptomatic; in the ER group 29.2% (p<0.05). Emergency treatment for acute ischemia, critical ischemia or rupture was necessary in 149 patients (22.5%) in the OR group vs. 11 patients (10.3%) in the ER group.
Most frequent complications after surgery were impaired wound healing (OR n=47, 7.1%; ER n=3, 2.8%, p>0.05) and major bleeding (OR n=26, 3.9%; ER n=3, 2.8%, p>0.05). In-hospital length of stay (= 10d [3-65] OR vs. x˜=7d [1-73] ER) was significantly higher in the OR group. Overall patency was 83.2% vs. 44.7% (OR/ER, p<0.005) after 12 months and 74.2% vs. 29.1% (OR/ER, p<0.005) after 24 months. There was a significantly poorer outcome for prosthetic graft compared to autologous vein in the OR group (71.4% vs. 88.1% 12-month primary patency).
 CONCLUSION: 
 In order to evaluate new treatment techniques such as endovascular repair (ER) for PAA, real world data is of essential importance. This analysis of the first results for the POPART registry shows good perioperative results for endovascular treatment of PAA in asymptomatic patients with good outflow vessels. The perioperative complication rate is low and the postoperative hospital stay is shorter than after OR. However, the patency rates after 12 and 24 months are low in the ER group compared to patients treated with open repair. More follow-up data is required for further interpretation; the completion of the data sets in the registry is ongoing.

Results After Open and Endovascular Repair of Popliteal Aneurysm: A Matched Comparison Within a Population Based Cohort

OBJECTIVE

To identify factors affecting the outcome after open surgical (OSR) and endovascular (ER) repair of popliteal artery aneurysm (PA) in comparable cohorts.

METHODS

A matched comparison in a national, population based cohort of 592 legs treated for PA (2008 - 2012), with long term follow up. Registry data from 899 PA patients treated in 2014 - 2018 were analysed for time trends. The 77 legs treated by ER were matched, by indication, with 154 legs treated with OSR. Medical records and imaging were collected. Analysed risk factors were anatomy, comorbidities, and medication. Elongation and angulations were examined in a core lab. The main outcome was occlusion.

RESULTS

Patients in the ER group were older (73 vs. 68 years, p = .001), had more lung disease (p = .012), and were treated with dual antiplatelet therapy or anticoagulants more often (p < .001). The hazard ratio (HR with 95% confidence intervals) for occlusion was 2.69 (1.60 - 4.55, p < .001) for ER, but 3.03 (1.26 - 7.27, p = .013) for poor outflow. For permanent occlusion, the HR after ER was 2.47 (1.35 - 4.50, p = .003), but 4.68 (1.89 - 11.62, p < .001) for poor outflow. In the ER subgroup, occlusion was more common after acute ischaemia (HR 2.94 [1.45 - 5.97], p = .003; and poor outflow HR 14.39 [3.46 - 59.92], p < .001). Larger stent graft diameter reduced the risk (HR 0.71 [0.54 - 0.93], p = .014). In Cox regression analysis adjusted for indication and stent graft diameter, elongation increased the risk (HR 1.020 per degree [1.002 - 1.033], p = .030). PAs treated for acute ischaemia had a median stent graft diameter of 6.5 mm, with those for elective procedures being 8 mm (p < .001). Indications and outcomes were similar during both time periods (2008 - 2012 and 2014 - 2018).

CONCLUSION

In comparable groups, ER had a 2.7 fold increased risk of any occlusion, and 2.4 fold increased risk of permanent occlusion, despite more aggressive medical therapy. Risk factors associated with occlusion in ER were poor outflow, smaller stent graft diameter, acute ischaemia, and angulation/elongation. An association between indication, acute ischaemia, and small stent graft diameter was identified.

Contemporary Treatment of Popliteal Artery Aneurysms in 14 Countries: A Vascunet Report

OBJECTIVE

Popliteal artery aneurysm (PAA) is the second most common arterial aneurysm. Vascunet is an international collaboration of vascular registries. The aim was to study treatment and outcomes.

METHODS

This was a retrospective analysis of prospectively registered population based data. Fourteen countries contributed data (Australia, Denmark, Finland, France, Hungary, Iceland, Italy, Malta, New Zealand, Norway, Portugal, Serbia, Sweden, and Switzerland).

RESULTS

During 2012-2018, data from 10 764 PAA repairs were included. Mean values with between countries ranges in parenthesis are given. The incidence was 10.4 cases/million inhabitants/year (2.4-19.3). The mean age was 71.3 years (66.8-75.3). Most patients, 93.3%, were men and 40.0% were active smokers. The operations were elective in 73.2% (60.0%-85.7%). The mean pre-operative PAA diameter was 32.1 mm (27.3-38.3 mm). Open surgery dominated in both elective (79.5%) and acute (83.2%) cases. A medial surgical approach was used in 77.7%, and posterior in 22.3%. Vein grafts were used in 63.8%. Of the emergency procedures, 91% (n = 2 169, 20.2% of all) were for acute thrombosis and 9% for rupture (n = 236, 2.2% of all). Thrombosis patients had larger aneurysms, mean diameter 35.5 mm, and 46.3% were active smokers. Early amputation and death were higher after acute presentation than after elective surgery (5.0% vs. 0.7%; 1.9% vs. 0.5%). This pattern remained one year after surgery (8.5% vs. 1.0%; 6.1% vs. 1.4%). Elective open compared with endovascular surgery had similar one year amputation rates (1.2% vs. 0.2%; p = .095) but superior patency (84.0% vs. 78.4%; p = .005). Veins had higher patency and lower amputation rates, at one year compared with synthetic grafts (86.8% vs. 72.3%; 1.8% vs. 5.2%; both p < .001). The posterior open approach had a lower amputation rate (0.0% vs. 1.6%, p = .009) than the medial approach.

CONCLUSION

Patients presenting with acute ischaemia had high risk of amputation. The frequent use of endovascular repair and prosthetic grafts should be reconsidered based on these results.

Ruptured Popliteal Artery Aneurysm Complicated with Acute Respiratory Distress Syndrome Secondary to SARS-CoV-2 Infection

We herein report a rare case of the ruptured popliteal artery aneurysm in an 89-year-old man, whose recovery after surgical treatment was complicated with acute respiratory distress syndrome secondary to confirmed infection with SARS-CoV-2. Presenting symptoms, patient's comorbidities, and postoperative course complicated with cardiac and respiratory failure leading to adverse outcome are discussed in this case report.

Big data in vascular surgery: registries, international collaboration and future directions

Given the increasing availability of large data set, small single-institutional series raise decreasing attention. Rapid expansion of technology from electronic medical records to easily accessible internet access, and widespread use and acceptance of registries in the medical world has allowed for research and quality improvement efforts using 'big data'. Big data, although technically not defined, typically refers to large databases that can be used to investigate common or rare disease processes or outcomes, describe variation in clinical practices across and between different specialties at various practice location, whilst allowing important information about trends over time. Big data have allowed investigators to quickly assimilate cohorts of patients and/or procedures to answer current questions, with more complete population representation and improved generalizability whilst decreasing the likelihood of power problems and type II errors. On the other hand, pitfalls still exist with the growing problem of hypothesis fishing, lack of granularity and the fear by many clinicians that registry transparency may have already gone too far, where surgery groups or individual surgeon outcomes are readily available to patients and referring providers. Within vascular surgery specifically, big data have expanded over the last decade and now includes regional, national and global registries that have major benefits of gathering specific clinical and procedural information within vascular surgery. In this review, we highlight the main vascular surgery registries and recap a few success stories of how the registries have been leveraged to benefit discovery, quality improvement and ultimately patient care. Additionally, we outline future directions that will be imperative for continued expansion, acceptance and adoption of 'big data' utilization inpatients with vascular disease.

Open repair with resection and reimplantation for popliteal artery aneurysm

Popliteal artery aneurysms are the most frequent type of peripheral arterial aneurysm and can be repaired by either open or endovascular techniques. An 81-year-old man presented with leg swelling and during duplex ultrasound examination was diagnosed a popliteal aneurysm. The transverse diameter was 3.6 × 4.5cm, length 2.8cm, one run-off vessel patent. The popliteal aneurysm was asymptomatic for clinical signs of limb ischaemia. We opted for an open surgical repair through a posterior approach. During dissection of the popliteal artery above and below the aneurysm, the two non-diseased popliteal extremities appeared to be very close, leading to the decision to perform an end-to-end anastomosis between the two arterial extremities. The patient was discharged after three days with no adverse events. Follow-up consisted of duplex ultrasound examination at one, three and six months, and then annually. At the six-month follow-up there was no restenosis at the anastomosis.

International Validation of the Population Based Malta Vascular Registry: A Vascunet Report

Introduction

Quality registries can be used to study treatment patterns and changes in trends of complications related to procedures and devices. To ensure that such study is possible in registries, there is a need to use standardised variables and the registry must have high internal and external validity. This study was an international external and internal validation of the newly initiated Maltese Vascular Registry.

Report

Two international vascular registry consultants visited the Maltese Vascular Registry (MVR), and conducted an external validation on all carotid and aortic aneurysm repairs performed in 2017-18. The external validation was conducted by comparing hospital administration lists with the MVR list. Using randomly chosen numbers, an internal validation was conducted of 20 random cases of carotid and 20 aortic aneurysms, 10 from 2017 and 10 from 2018, to validate date of operation and procedure against the patient's medical record. The registry is built as a database using national personal identifier codes, with variables for date and type of procedure, and anaesthetic method used, to which a note is attached describing the indication, intervention, and follow up. Between the hospital registry and the MVR, 111 of 115 cases could be identified correctly, corresponding to 97% external validity. Between the patient case records and the MVR, the dates and procedures of 20/20 carotid and 20/20 aortic aneurysm procedure were identical, indicating 100% internal validity.

Discussion

The MVR showed an external validity of 97% and internal validity of 100%. Future work should incorporate specific variables for comorbidity, procedures, and outcomes, with the registry aiming to incorporate international recommended variables for comorbidity, procedure, and outcome.

A Comparison of Endovascular Versus Open Repair of Popliteal Artery Aneurysms: An Updated Meta-Analysis

OBJECTIVE

Traditionally, popliteal artery aneurysms (PPAs) were treated via open repair (OR). However, more recently endovascular repair (EVR) approaches have become more common for the treatment of PPAs. The present meta-analysis therefore sought to conduct an up-to-date review of studies comparing the relative safety and efficacy of these 2 repair strategies. To that end, patient outcomes including primary patency, operating time, hospital stay duration, and re-intervention, amputation, and graft occlusion within 30 days were compared for these OR and EVR approaches.

METHODS

Studies in which OR and EVR were compared as treatments for PPAs were identified through systematic searching of the PubMed and Embase databases. Any studies either analyzing only one of these treatments in isolation or analyzing <5 patients were not included in this analysis. For all relevant studies, patient demographic information and outcome details were compiled. Risk of bias was analyzed using a modified Newcastle-Ottawa Scale. The odds ratios, mean differences, and hazard ratios (HRs) for patient outcomes were estimated using a random-effects model.

RESULTS

In total, we identified 17 relevant studies including a single randomized controlled trial and 16 retrospective cohort studies, incorporating 6887 total cases (1662 EVR and 5225 OR). The quality of evidence for all measured outcomes was deemed to be very low or low according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Rates of primary patency were found to be significantly higher for patients treated via OR relative to those treated via EVR (HR = 1.60; 95% confidence interval [CI]: 1.12-2.30; P = .03). Operative and hospitalization durations, in contrast, were significantly lower for patients treated via EVR. Patients treated via EVR also experienced significantly higher rates of graft thrombosis and reintervention within 30 days relative to patients treated via OR. However, no significant differences were observed between treatments with respect to rates of patient amputation (OR = 1.01; 95% CI: 0.55-1.85; P = .98).

CONCLUSIONS

The available data suggest that PPA repair via EVR is a safe alternative to OR, but that short-term graft thrombosis and reintervention rates are significantly greater for the former approach. Moreover, few studies to date have compared these techniques and those that were largely retrospective in nature with relatively low-quality evidence, making it difficult to make definitive statements regarding the relative safety and efficacy of these 2 repair strategies. Additional population-based large-scale studies are therefore essential in order to conduct a robust evaluation of the safety and utility of EVR as an alternative to OR for PPA repair.

Effect of Intra-operative Intra-arterial Thrombolysis on Long Term Clinical Outcomes in Patients with Acute Popliteal Artery Aneurysm Thrombosis

OBJECTIVE

Acute lower limb ischaemia (ALI) as a result of popliteal artery aneurysm (PAA) thrombosis represents a significant problem. The aim of this study was to investigate outcome of intra-operative intra-arterial thrombolysis in the treatment of acute ischaemia due to PAA thrombosis in terms of major adverse limb events (MALE), overall survival, and intrahospital complications, especially those associated with bleeding.

METHODS

A total of 156 patients with Rutherford grade IIa and IIb acute ischaemia resulting from PAA thrombosis were admitted between 1 January 2011 and 1 January 2017. The patients were divided into two groups, those who underwent additional treatment with intra-operative intra-arterial thrombolysis (20 patients), and those who did not (136 patients). By using covariables from baseline and angiographic characteristics, a propensity score was calculated for each patient. Each patient who underwent intra-operative thrombolysis was matched to four patients from the non-thrombolysis group. Thus, comparable patient cohorts (20 in the thrombolysis and 80 in the non-thrombolysis group) were identified for further analysis. The primary end point was MALE and the secondary endpoint all cause mortality.

RESULTS

After a median follow up of 55 months, the estimated MALE rate was significantly lower in the thrombolysis group (30% vs. 65%, chi square = 10.86, p < .001, log rank test). Also, patients in the thrombolysis group had a significantly lower mortality rate (20% vs. 42.65%, chi square = 3.65, p = .05, log rank test). The thrombolysis group had wound/haematoma related interventions performed more commonly (25% in thrombolysis vs 8%, in non-thrombolysis group), but the difference was not significant (p=.013). There were no cases of major (intracranial and gastrointestinal) bleeding in either group.

CONCLUSION

The data suggest that intra-operative thrombolysis in the treatment of selected patients with ALI due to PAA thrombosis has long term MALE and overall survival benefits, without a significant risk of major, life threatening bleeding complications.

Endovascular versus open repair of asymptomatic popliteal artery aneurysm

BACKGROUND

Popliteal artery aneurysm (PAA) is a focal dilatation and weakening of the popliteal artery. If left untreated, the aneurysm may thrombose, rupture or the clot within the aneurysm may embolise causing severe morbidity. PAA may be treated surgically by performing a bypass from the arterial segment proximal to the aneurysm to the arterial segment below the aneurysm, which excludes the aneurysm from the circulation. It may also be treated by a stent graft that is inserted percutaneously or through a small cut in the groin. The success of the procedure is gauged by the ability of the graft to stay patent over an extended duration. While surgical treatment is usually preferred in an emergency, the evidence on first line treatment in a non-emergency setting is unclear. This is an update of a review first published in 2014.

OBJECTIVES

To assess the effectiveness of an endovascular stent graft versus conventional open surgery for the treatment of asymptomatic popliteal artery aneurysms (PAA) on primary and assisted patency rates, hospital stay, length of the procedure and local complications.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 29 January 2019.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing endovascular stent grafting versus conventional open surgical repair in patients undergoing unilateral or bilateral prophylactic repair of asymptomatic PAAs.

DATA COLLECTION AND ANALYSIS

We collected data on primary and assisted primary patency rates (primary endpoints) as well as operating time, the length of hospital stay, limb salvage and local wound complications (secondary endpoints). We presented results as risk ratio or mean difference with 95% confidence intervals and assessed the certainty of the evidence using GRADE.

MAIN RESULTS

No new studies were identified for this update. A single RCT with a total of 30 PAAs met the inclusion criteria. There was a low risk of selection bias and detection bias. However, the risks of performance bias, attrition bias and reporting bias were unclear from the study. Despite being an RCT, the certainty of the evidence was downgraded to moderate due to the small sample size, resulting in wide confidence intervals (CIs); only 30 PAAs were randomised over a period of five years (15 PAAs each in the groups receiving endovascular stent graft and undergoing conventional open surgery). The primary patency rate at one year was 93.3% in the endovascular group and 100% in the surgery group (RR 0.94, 95% CI 0.78 to 1.12; moderate-certainty evidence). The assisted patency rate at one year was similar in both groups (RR 1.00, 95% CI 0.88 to 1.13; moderate-certainty evidence). There was no clear evidence of a difference between the two groups in the primary or assisted patency rates at four years (13 grafts were patent from 15 PAA treatments in each group; RR 1.00, 95% CI 0.76 to 1.32; moderate-certainty evidence); the effects were imprecise and compatible with the benefit of either endovascular stent graft or surgery or no difference. Mean hospital stay was shorter in the endovascular group (4.3 days for the endovascular group versus 7.7 days for the surgical group; mean difference (MD) -3.40 days, 95% CI -4.42 to -2.38; P < 0.001; moderate-certainty evidence). Mean operating time was also reduced in the endovascular group (75.4 minutes in the endovascular group versus 195.3 minutes in the surgical group; MD -119.90 minutes, 95% CI -137.71 to -102.09; P < 0.001; moderate-certainty evidence). Limb salvage was 100% in both groups. Data on local wound complications were not published in the trial report.

AUTHORS' CONCLUSIONS

Evidence to determine the effectiveness of endovascular stent graft versus conventional open surgery for the treatment of asymptomatic PAAs is limited to data from one small study. At one year there is moderate-certainty evidence that primary patency may be improved in the surgery group but assisted primary patency rates were similar between groups. At four years there was no clear benefit from either endovascular stent graft or surgery to primary or assisted primary patency (moderate-certainty evidence). As both operating time and hospital stay were reduced in the endovascular group (moderate-certainty evidence), it may represent a viable alternative to open repair of PAA. A large multicenter RCT may provide more information in the future. However, difficulties in recruiting enough patients are likely, unless it is an international collaboration including a number of high volume vascular centres.

[Treatment of Peripheral Aneurysms - Dual Supera for Popliteal Artery Aneurysms: Immediate and Long-Term Results]

Popliteal aneurysms have the highest incidence of all peripheral aneurysms. The clinical symptoms are dominated by chronic embolism, resulting in irreversible ischemia with the associated risk of amputation and mortality, but rupture is less important. Acute aneurysm thrombosis bears a high risk of amputation and mortality. Endovascular exclusion with covered stents instead of open surgery has gained widespread acceptance and is based on reliable data. The principle of flow diversion for aneurysm treatment is well known for the cerebral vasculature, and is now emerging as a potential alternative with promising results and is challenging the concept of complete endovascular aneurysm exclusion or surgical bypassing. Since 2011, thirty-four out of 142 electively treated popliteal aneurysms and 8 thrombosed aneurysms were treated with a bare metal woven Nitinol stent. In this single centre series with continuous mid- to long-term follow-up, as described below, this option showed reliable results in terms of clinical outcome, material fatigue and preservation of outflow vasculature with the option for conversion. The limitation of the technique is determined by the available maximum outer stent diameter of 7.5 mm.

Prevalence of Synchronous and Metachronous Aneurysms in Women With Abdominal Aortic Aneurysm

BACKGROUND

Abdominal aortic aneurysm (AAA) is three to five times more common among men compared with women, yet up to 38% of all aneurysm related deaths affect women. The aim of this study was to estimate the prevalence of synchronous or metachronous aneurysms among women with AAA, as diagnosis and treatment could improve survival.

PATIENTS AND METHODS

This is a retrospective study of prospectively registered patients. All women operated on, or under surveillance for, AAA were identified at two Swedish hospitals. Aneurysms in different locations were identified using available imaging studies. Aneurysms were defined according to location: thoracic ascending aorta ≥42 mm, descending ≥33 mm, abdominal aorta ≥30 mm, common iliac artery ≥20 mm or 50% wider than the contralateral artery, common femoral artery ≥12 mm, popliteal artery ≥10 mm.

RESULTS

A total of 339 women with an AAA were included. The median follow up was 2.8 (range 0-15.7) years. Thirty-one per cent had an aneurysm in the thoracic aorta (67 of 217 investigated, 84% were located in the descending aorta), 13 (19%) underwent repair. Twelve per cent had a common iliac artery aneurysm (24/259, 76% were investigated). Common femoral artery aneurysms were identified in 4.3% (8/184, 54% investigated). Popliteal artery aneurysms were identified in 4.0% (6/149, 44% investigated). The prevalence of infrainguinal aneurysms was higher among patients with synchronous iliac aneurysms (40% vs. 1.6%, OR 42, 95% CI 6.4-279, p < .001).

CONCLUSIONS

Thoracic aortic aneurysms are common among women with AAA, most commonly affecting the descending aorta, and detection frequently results in repair. Popliteal and femoral aneurysms are not rare among women with AAA, and even common if there is a synchronous iliac aneurysm.

Popliteal Artery Aneurysm in Women

OBJECTIVES

Ninety-five per cent of those operated on for popliteal artery aneurysm (PA) are men. Thus, PAs in women are difficult to investigate. The aim was to study the disease in women.

METHODS

Women treated for PA in 1987-2012, prospectively registered in the Swedish vascular registry, Swedvasc, supplemented by case records, were compared with the larger male cohort. Survival was determined through cross linkage with the National Population Registry.

RESULTS

1509 patients (men and women), 1872 legs, were identified; of these 74 patients (4.9%) were women, 81 legs (4.3%). The median age was 70 years in women versus 69 in men. Twenty-nine centres operated on women (range 1-7 women/centre). There were no time trends in the proportion of women operated on (p=.5). Bilateral PA occurred in 9.5% of women and 27.0% of men (p=.002). For symptomatic aneurysms, there was a larger proportion of small aneurysms (<2 cm) among women than men (24% vs. 8%, p=.005), there was no such difference in asymptomatic aneurysms. Distribution between asymptomatic and symptomatic PA was 31% versus 69%, similar to men. The prevalence of concomitant aneurysms in the aorto-iliac and femoral arteries, and the frequency of presenting symptoms were similar compared with men. Three PA were ruptured (3.7%). Thrombolysis was used in 23 of 45 legs treated for acute ischaemia (51%). Eight legs were treated with endovascular stent grafts (9.8%), compared with 7.9% in men (p=.5). Seven legs were amputated (8.6%). Crude survival was similar to men.

CONCLUSIONS

PA is similar in women and men, but bilateral disease was less common in women and symptomatic PA were more often <2 cm in diameter. Women had the same survival as men, despite women generally having better life expectancy. Although the largest series ever published on women with PA, the sample size is small, making it prone to type II statistical error.

Meta-analysis of open and endovascular repair of popliteal artery aneurysms

OBJECTIVE

Endovascular popliteal artery aneurysm repair (EPAR) is increasingly used over open surgical repair (OPAR). The purpose of this study was to analyze the available literature on their comparative outcomes.

METHODS

The PubMed and Embase databases were searched to identify studies comparing OPAR and EPAR. Studies with only one treatment and fewer than five patients were excluded. Demographics and outcomes were collected. Bias risk was assessed using a modified version of the Newcastle-Ottawa Scale. Results were computed from random-effects meta-analyses using the DerSimonian-Laird algorithm.

RESULTS

A total of 14 studies were identified encompassing 4880 popliteal artery aneurysm repairs (OPAR, 3915; EPAR, 1210) during the last decade. OPAR patients were younger (standard mean difference, -0.798 [-0.798 to -1.108]; P < .001) and more likely to have worse tibial runoff (odds ratio [OR], 1.949 (1.15-3.31); P = .013) than EPAR patients. OPAR had higher odds of wound complications (OR, 5.182 [2.191-12.256]; P < .001) and lower odds of thrombotic complications (OR, 0.362 [0.155-0.848]; P < .001). OPAR had longer length of stay (standardized mean difference, 2.158 [1.225-3.090]; P < .001) and fewer reinterventions (OR, 0.275 [0.166-0.454]; P < .001). Primary patency was better for OPAR at 1 year and 3 years (relative risk, 0.607 [P = .01] and 0.580 [P = .006], respectively). There was no difference in secondary patency at 1 year and 3 years (0.770 [P = .458] and 0.642 [P = .073], respectively).

CONCLUSIONS

EPAR has a lower wound complication rate and shorter length of hospital stay compared with OPAR. This comes at the cost of inferior primary patency but not secondary patency out to 3 years. Studies reporting long-term outcomes are lacking and necessary.

Cardiovascular Risk Reduction is Important for Improving Patient and Graft Survival After Ligation and Bypass Surgery for Popliteal Artery Aneurysm

OBJECTIVES

To report outcomes following ligation and bypass (LGB) surgery for popliteal artery aneurysm (PAA) and study factors influencing patient and graft survival.

MATERIALS AND METHODS

A retrospective review of patients undergoing LGB surgery for PAA between September 1999 and August 2012 at a tertiary referral vascular unit was performed. Primary graft patency (PGP), primary-assisted graft patency (PAGP), and secondary graft patency (SGP) rates were calculated using survival analyses. Patient, graft aneurysm-free survival (GAFS), aneurysm reperfusion-free survival (ARFS), and amputation-free survival (AFS) rates were also calculated. Log-rank testing and Cox proportional hazards modeling were used to perform univariate and multivariate analysis of influencing factors, respectively.

RESULTS

Eighty-four LGB repairs in 69 patients (mean age 71.3 years, 68 males) were available for study. The 5-year PGP, PAGP, SGP, and patient survival rates were 58.1%, 84.4%, 85.2%, and 81.1%, respectively. On multivariate analysis, the principal determinants of PGP were urgency of operation ( P = .009) and smoking status ( P = .019). The principal determinants of PAGP were hyperlipidemia status ( P = .048) and of SGP were hyperlipidemia ( P = .042) and cerebrovascular disease (CVD) status ( P = .045). The principal determinants of patient survival were previous myocardial infarction ( P = .004) and CVD ( P = .001). The 5-year GAFS, ARFS, and AFS rates were 87.9%, 91.6%, and 96.1%, respectively.

CONCLUSION

This study has shown that traditional cardiovascular risk factors, such as a smoking and ischemic heart disease, are the most important predictors of early graft failure and patient death following LGB surgery for PAA.

Contemporary outcomes of open and endovascular popliteal artery aneurysm repair

OBJECTIVE

The purpose of this study was to evaluate contemporary practice and outcomes of open repair (OR) or endovascular repair (ER) for popliteal artery aneurysms (PAAs).

METHODS

Consecutive patients with PAA treated at one institution from January 2006 to March 2014 were reviewed under an Institutional Review Board-approved protocol. Demographics, indications, anatomic characteristics, and outcomes were collected. Standard statistical methods were used.

RESULTS

A total of 186 PAAs were repaired in 156 patients (110 ORs, 76 ERs) with a mean age of 71 ± 11 years, and most were male (96%). Mean follow-up was 34.9 ± 28.6 months for OR and 28.3 ± 25.8 months for ER (P = .12). Comorbidities were similar between groups. OR was used in more patients with PAA thrombosis (41.8% vs 5.3%; P < .001), acute ischemia (24.5% vs 9.2%; P = .010), and ischemic rest pain (34.5% vs 6.6%; P < .001). Mean tibial (Society for Vascular Surgery) runoff score was 5.0 for OR vs 3.3 for ER (P = .006). OR was associated with increased 30-day complications (22% vs 2.6%; P < .001) and mean postoperative stay (5.8 vs 1.6 days; P < .001). There was no difference in 30-day mortality (OR, 1.8%; ER, 0%; P = .56) or major amputation rate (OR, 3.7%; ER, 1.3%; P = .65). Primary, primary assisted, and secondary patency rates were similar at 3 years (OR, 79.5%, 83.7%, and 85%; ER, 73.2%, 76.3%, and 83%; P = NS). Among 130 patients presenting electively without acute ischemia or thrombosed PAA (63 ORs and 67 ERs), OR had better 3-year primary patency (88.3% vs 69.8%; P = .030) and primary assisted patency (90.2% vs 73.5%; P = .051) but similar secondary patency (90.2% vs 82%; P = .260). ER thrombosis was noted in 8 of 24 patients treated in 2006-2008 (33%; mean time to failure, 49 months) but in only 4 of 51 patients treated in 2009-2013 (7.8%; mean time to failure, 30 months), suggesting a steep learning curve.

CONCLUSIONS

ER is a safe and durable option for PAA, with lower complication rates and a shorter length of stay. OR has superior primary patency in patients treated electively but no difference in midterm secondary patency and amputations.

Two Decades of Endovascular Repair of Popliteal Artery Aneurysm--A Meta-analysis

OBJECTIVE/BACKGROUND

Over the last two decades endovascular repair (EVR) of popliteal artery aneurysms has emerged as a treatment alternative to conventional open surgical repair (OSR). The aim of this review was to evaluate the safety and efficiency of each repair method, comparing the following outcomes after EVR and OSR: (i) primary patency; (ii) operating time; (iii) length of hospital stay; (iv) peri-operative complications; (v) limb salvage; and (vi) patient survival.

METHODS

The PubMed and Cochrane Central Register of Controlled Trials were searched for publications that compared outcomes after EVR and OSR (last search November 2014). Randomized controlled trials (RCTs), prospective and retrospective observational cohort studies were included. The quality of studies was evaluated using the Newcastle-Ottawa scale and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Random effect models were employed to estimate odds ratios (ORs), mean differences, and hazard ratios (HRs).

RESULTS

One RCT combined with a prospective cohort study and four retrospective cohort studies with an overall total of 652 cases (236 EVR, 416 OSR) were identified. GRADE quality of evidence was low or very low for all outcomes. After a median follow up of 33 months, patients who received EVR showed equal primary patency rates to patients who received OSR (HR 1.46, 95% confidence interval [CI] 0.92-2.33). Lengths of operation and hospitalization were significantly shorter following EVR; rates of 30 day graft thrombosis (OR 3.16, 95% CI 1.31-7.62) and 30 day re-intervention (OR 2.15, 95% CI 1.02-4.55) were significant higher for patients who received EVR compared with those who received OSR. There was no effect on mortality (OR 2.31, 95% CI 0.37-14.49) or limb loss (OR 0.59, 95% CI 0.16-2.15).

CONCLUSION

EVR of popliteal artery aneurysm showed mid-term results comparable to open surgery and appears to be a safe alternative to OSR. However, the existing empirical evidence base is too fragmentary to draw firm conclusions. Further research and the introduction of population based registries will be needed to allow reliable evaluation of EVR.

Endovascular versus open repair of asymptomatic popliteal artery aneurysm

BACKGROUND

Popliteal artery aneurysm (PAA) is a focal dilatation and weakening of the popliteal artery. If left untreated, the aneurysm may thrombose, rupture or the clot within the aneurysm may embolise causing severe morbidity. PAA may be treated surgically by performing a bypass from the arterial segment proximal to the aneurysm to the arterial segment below the aneurysm, which excludes the aneurysm from the circulation. It may also be treated by a stent graft that is inserted percutaneously or through a small cut in the groin. The success of the procedure is gauged by the ability of the graft to stay patent over an extended duration. While surgical treatment is usually preferred in an emergency, the evidence on first line treatment in a non-emergency setting is unclear.

OBJECTIVES

To assess the effectiveness of an endovascular stent graft versus conventional open surgery for the treatment of asymptomatic popliteal artery aneurysms (PAA) on primary and assisted patency rates, hospital stay, length of the procedure and local complications.

SEARCH METHODS

The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched their Specialised Register (last searched June 2014) and CENTRAL (2014, Issue 5). Clinical trials databases were searched for any ongoing or unpublished studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing endovascular stent grafting versus conventional open surgical repair in patients undergoing unilateral or bilateral prophylactic repair of asymptomatic PAAs were included.

DATA COLLECTION AND ANALYSIS

Data were collected on primary and secondary patency rates (primary endpoints) as well as operating time, the length of hospital stay, limb salvage and local wound complications (secondary endpoints).

MAIN RESULTS

A single RCT was identified that conformed to the inclusion criteria. There was a low risk of selection bias and detection bias. However, the risks of performance bias, attrition bias and reporting bias were unclear from the study. Despite being an RCT, the level of evidence was downgraded to moderate due to the small sample size, resulting in wide confidence intervals (CIs); only 30 PAAs were randomised over a period of five years (15 PAAs each in the groups receiving endovascular stent graft and undergoing conventional open surgery). The primary patency rate at one year was 100% in the surgery group and 93.3% in the endovascular group (P = 0.49). However, the assisted patency rate at one year was similar in both groups (100% patency). There was no clear evidence of a difference between the two groups in the primary or secondary patency rates at four years (13 grafts were patent from 15 PAA treatments in each group). However, the effects were imprecise and compatible with the benefit of either endovascular stent graft or surgery or no difference. Mean hospital stay was shorter in the endovascular group (4.3 days for the endovascular group versus 7.7 days for the surgical group; mean difference (MD) -3.40 days, 95% CI -4.42 to -2.38; P < 0.001). Mean operating time was also reduced in the endovascular group (75.4 minutes in the endovascular group versus 195.3 minutes in the surgical group; MD -119.20 minutes, 95% CI -137.71 to -102.09; P < 0.001). Limb salvage was 100% in both groups. Data on local wound complications were not published in the trial report.

AUTHORS' CONCLUSIONS

Due to the limitations of the current evidence from one small underpowered study, we are unable to determine the effectiveness of endovascular stent graft versus conventional open surgery for the treatment of asymptomatic PAAs. A larger ongoing multicentre RCT should provide more information in the future. However, it seems reasonable to suggest that endovascular repair should be considered as a viable alternative to open repair of PAA on a case by case basis.

[Establishment and functioning of the Vascular Registry in Hungary]

Randomized controlled trials provide the best evidence in clinical trials; however, they do have limitations. In order to evaluate the effectiveness of treatments, population based registries may also yield useful information about the actual practice and they may enable users to carry out a dynamic follow-up. To evaluate the outcome of vascular procedures, the Vascular Registry in Hungary has been established in 2002. This article presents the establishment and functioning of the Vascular Registry and provides information about scientific results obtained during the past years. The Vascular Registry is an internet based database with on-line input. The backup server is provided by the National Institute for Quality and Organizational Development in Healthcare and Medicines. The database collects data in three different fields: interventions for carotid artery, aneurysm (any type) and lower extremity vascular diseases. Twenty five vascular surgical units record interventions in the registry, which corresponds to two thirds of the whole activity. Since joining the Vascunet Group of the European Society for Vascular Surgery, the registry has contributed to several publications based on evaluation of a large common dataset in different fields of vascular surgery. A validation process has been recently performed which confirmed the internal and external validity of the database. The authors conclude that despite unsolved problems related to financing issues, the Vascular Registry has proved to be a useful tool during the past years. In order to take advantage of the registry to its fullest, measures should be taken to achieve a more complete data recording, increase publication activity on the national dataset, improve the flow of information during operation and develop a system of regular feedback.